Clinical fetal heart failure occurs in conditions associated with increasing left and right atrial filling and/or central venous pressures and manifests as right heart failure with the development of pericardial and pleural effusions, ascites and peripheral and placental edema. Fetal heart failure may occur in primary myocardial disease, in presence of the extracardiac pathology impacting the loading conditions of the fetal heart and in conditions associated with secondary myocardial dysfunction including structural heart defects, bradycardia or tachycardia. This review summarizes recent literature of the understanding of the normal fetal circulation and the pathogenic mechanisms responsible for the evolution of fetal heart failure, strategies for fetal and perinatal management of fetal heart failure, and future directions that may lead to novel strategies to treat affected pregnancies and.